Utilization & Reimbursement Specialist

Socket.dev; Council Bluffs (IA); On-site; USD 45,000 - 65,000; Full time

Job summary

Socket.dev in Council Bluffs, IA seeks a qualified professional to monitor utilization and optimize reimbursement for the facility. You will act as liaison between managed care organizations and the clinical staff, performing reviews and coordinating communications on reimbursement requirements.

Responsibilities include tracking length of stay, gathering reports, ensuring medical necessity, and coordinating pre-certifications and appeals.

Qualifications

• Requires clinical experience, or two+ years in the facility's population.
• Preferred licensure: LPN, RN, LMSW, LCSW, LPC, or similar.
• CPR and de-escalation certification required (training provided).
• First aid may be required.

Responsibilities

• Act as liaison between managed care organizations and facility clinical staff.
• Conduct reviews in accordance with certification requirements and coordinate reimbursement communications.
• Monitor patient length of stay and inform staff on issues affecting length of stay.
• Gather and develop statistical and narrative information to report on utilization, discharges, quality of services.
• Conduct quality reviews for medical necessity and services provided.
• Facilitate peer review calls between facility and external organizations.
• Initiate and complete the formal appeal process for denied admissions or continued stay.
• Assist the admissions department with pre-certifications of care.
• Provide ongoing support and training for staff on documentation or charting requirements.

Skills

Utilization management

Clinical liaison

Data analysis & reporting

Staff training

Education

High school diploma or equivalent

Associate's/Bachelor's/Master’s in Social Work or Nursing or related health field

Job description

Socket.dev in Council Bluffs, IA seeks a qualified professional to monitor utilization and optimize reimbursement for the facility. You will act as liaison between managed care organizations and the clinical staff, performing reviews and coordinating communications on reimbursement requirements.

Responsibilities include tracking length of stay, gathering reports, ensuring medical necessity, and coordinating pre-certifications and appeals.